RDelCastilloUPDiliman2014 PDF

COPYRIGHT DR.
RONALD DEL CASTILLO

White Island, Camiguin 2014
University of the Philippines, Diliman, September 12, 2014
DSM-5 & ICD-10:

Dr. Ronald Del Castillo
Update and Review of Clinical Psychologist
Psychopathology
COPYRIGHT DR. RONALD DEL CASTILLO
Objectives
❖ Key Changes. Identify key changes from earlier revisions of the
DSM-5 with the aim of developing and refining skills to better
diagnose and ultimately treat a broad range of psychopathology.
❖ Survey Course. Identify common psychopathology, including
symptomatology, etiology, course, and best-practice treatments.
❖ Similarities and Differences. Identify intersections and divergence
between the DSM-5 and ICD-10.
❖ Diversity. Identify social determinants of mental health, such as
culture, gender, socioeconomic status, and other diversity issues.
Key (Broad) Distinctions
Source: American Psychological Association

Who writes it?
DSM ICD
American Psychiatric World Health Organization

Association (APA) (WHO)

a single national professional a global health agency with a
association public health mission
Who approves it?
DSM ICD
assembly of the American health ministers of all 194

Psychiatric Association members of the WHO
What is the cost?
DSM ICD
- widely distributed at
- substantial portion of
very low cost
APA revenue is from
- substantial discounts
book sale, related
for low-income
products, and
countries
copyright permissions
- free on the internet
Who is the audience?
DSM ICD
global, multidisciplinary,
psychiatrists in the
and multilingual
United States
professionals worldwide
Where is the data from?
DSM ICD
Field field trials in Field trials in 110

academic, clinical, and academic, clinical, and
private practice settings private practice settings
in the U.S. and Canada in 40 countries*
*ICD-10: The Philippines was not

involved. No field trials were
conducted in the Philippines. No
Filipino principal investigators
participated in the development of the
ICD-10.
ICD-10: A Closer Look

ICD: Objectives
The 194 member countries of the WHO agree to utilize the ICD as the
standard approach for collecting and reporting health information.
❖ To monitor epidemics/threats to public health/disease burden
❖ To identify vulnerable/at risk populations
❖ To define obligations of WHO member countries to provide free or
subsidized health care to their populations
❖ To facilitate access to appropriate health care services
❖ As a basis for guidelines for care and standards of practice
❖ To facilitate research into more effective treatment
Who uses the ICD?

Study of 4,887 participating psychiatrists (Reed et al., World
Psychiatry, 2011)
❖ North and South America: 540
❖ Europe and Russia: 2,774
❖ Africa: 83
❖ Eastern Mediterranean: 315
❖ Southeast Asia: 463
❖ Western Pacific: 712
In your day-to-day clinical work, which classification system for

mental disorder do you use most?
70
52.5
35
17.5
0
ICD-10 ICD-9 or ICD-8 DSM-IV Other
What are the implications?

Two major classifications of mental disorders:
❖ hinders the collection and use of national statistics
❖ hinders the design of clinical trials aimed at developing
new treatments or interventions
❖ hinders international regulatory agencies from globally
applying results of clinical trials
❖ complicates the replication of scientific results across
national boundaries
Berlin 2012
Changes from DSM-IV-TR to DSM 5
DSM 5: Highlights What? Why? How?
of Changes
MAJOR CHANGES
FROM DSM-IV-TR TO DSM-5
*NOT an exhaustive list

Source: Highlights of Changes from DSM-IV-TR to
DSM-5, American Psychiatric Association
Major Changes
Change Comment
- more simplified
No multiaxial system
- poor distinction between Axis I and
No global assessment of functioning
II in DSM-IV
(GAF)
- external factors can still be specified
- groupings based on shared or similar
Twenty (20) diagnostic classes or characteristics
categories of mental disorders - spectrums of related disorders are
included
More dimensionality with the use of - recognition that categorical ratings

severity ratings can be limiting
Multiaxial System: Then & Now

DSM-IV-TR DSM-5

Axis I: 309.81 PTSD with acute onset, 309.81 PTSD with dissociative
311 Depressive Disorder NOS, 300.01 symptoms (depersonalization) and with
Panic Disorder Without Agoraphobia, panic attacks
300.6 Depersonalization Disorder 333.94 Restless legs syndrome
Axis II: None 995.83 Adult sexual abuse by non-
Axis III: 333.94 Restless legs syndrome partner (rape)
Axis IV: Occupational problems (on V62.89 Victim of crime
leave), problems with primary support V61.10 Relationship problem with
(conflict with partner), problems related intimate partner
to crime (victim of rape) V62.29 Other problem related to
Axis V: GAF = 41 employment
Major Changes
Change Comment
More emphasis on comorbidity (e.g.,

- recognition of dimensionality of
use of anxiety ratings in diagnosing
disorders
depressive and bipolar disorders)
- increasing evidence that obsessions,

New category: Obsessive-Compulsive
compulsions, and similar disorders
and Related Disorders
are related to one other
New category: Trauma and Stressor- - stress-related disorders are grouped

Related Disorder under the same category
Major Changes
Change Comment
Transformed: Neurodevelopmental - more emphasis on neurobiological

Disorders (formerly Disorders Usually bases of mental disorders
First Diagnosed in Infancy or - many disorders previously classified
Adolescence) with childhood onset
- misunderstood term
Transformed: Somatic Symptom and
- emphasis on psychological reactions
Related Disorders (formerly
to physical symptoms, not whether
Somatoform Disorders)
they are medically based
- includes Gambling Disorder
Transformed: Substance-Related and
- others still remain under study and
Addictive Disorders (formerly
not included in new edition (e.g.,
Substance Use Disorders)
compulsive shopping, Internet use)
Major Changes
Change Comment
- limited evidence to show distinction

No distinction between substance abuse between abuse and dependence
and substance dependence, now a disorders
single category - inclusion of compulsive patterns in
addictive behaviors
Transformed: (1) Depressive Disorders

and (2) Bipolar & Related Disorders - two separate categories
(formerly Mood Disorders)
- recognition that depressive episode

No bereavement exclusion from
may include a normal/adaptive
depression
reaction to loss
DIAGNOSTIC CATEGORIES
What we WILL cover What we WILL NOT cover
Neurodevelopmental Disorders Dissociative Disorders

Schizophrenia Spectrum & Other Somatic Symptoms & Related Disorders
Psychotic Disorders Elimination Disorders
Bipolar & Related Disorders Sleep-Wake Disorders
Depressive Disorders & Suicide Sexual Dysfunctions
Anxiety Disorders Gender Dysphoria
Obsessive-Compulsive & Related Disruptive, Impulse-Control & Conduct
Disorders Disorders
Trauma- & Stressor-Related Disorders Paraphilic Disorders
Feeding & Eating Disorders Other Mental Disorders
Substance-Related & Addictive Medication-Induced Movement
Disorders Disorders and Other Adverse Effects of
Neurocognitive Disorders Medication
Personality Disorders Other Conditions That May Be A Focus
Cultural Considerations & Cultural of Clinical Attention
Formulation
DSM-5 & ICD-10: Diagnostic Codes

If there is only one ICD-10 code
DSM-5 (ICD-9) assigned to a disorder, it can be
Code found at the top of the criteria set
(as shown here).
Schizophrenia
Diagnostic Criteria 295.90 (F20.9)
ICD-10 Code

DSM-5 (ICD-9)
Specify whether: Code

295.70 (F25.0) Bipolar type: This subtype applies if a manic episode is part of the
presentation. Major depressive episodes may also occur.

295.70 (F25.1) Depressive type: This subtype applies if only major depressive
episodes are part of the presentation.
If more than one code can be assigned

to a disorder, the codes can be found at
the bottom of the diagnostic criteria
ICD-10 Code box. This is (usually) the case when
subtypes are coded.

DSM-5 (ICD-9) For disorders with more complex coding,
Code coding notes and coding tables are
provided at the bottom of the criteria box.
Specify if:

With catatonia (refer to the criteria for catatonia associated with another mental
disorder, pp. 119-120, for definition)

Coding note: Use additional code 293.89 (F06.1) catatonia associated with
schizoaffective disorder to indicate the presence of the comorbid catatonia.
ICD-10 Code
Note on Terminology: Seminar-Workshop

❖ Normal and Abnormal: What is and what is not within cultural expectations
of normative behavior?
❖ Criteria: What symptoms are needed to meet diagnosis?
❖ Symptoms (sxs): What does the illness look like?
❖ Associated Features: What are other characteristics of the disorder, in addition
to those symptoms for diagnosis?
❖ Etiology: What might be some origins ("causes") of the illness?
❖ Treatment (tx): What are the best ways to help the patient?
❖ Disorder (dx): What is the "official name" of the mental illness?
❖ History of (h/o): What does the past tell us?
Pop Quiz
Pop Quiz
Marisol is a 23-year-old recent graduate of the psychology program at UP Diliman.
In the last 3 weeks, her mood has been low, and at times, her friends have noticed
that she easily gets irritable. During those weeks she has slept for up to 12 hours, at
times skipping dinner or breakfast because she either overslept or she has little-to-no
appetite. She reports losing some weight in the past few weeks. She has difficulty
concentrating for the board exam, which she will take in about a month, although
she reports being able to study sufficiently for her needs. She feels tired most of the
time, nearly every day. She describes feeling worthless, although she does not
endorse thoughts of death or suicide. She has lost interest in some hobbies, like
going for a jog around campus or reading books. She reports being able to go to
part-time work at the local coffee shop and to volunteer at a local crisis center for
street children. She continues to see friends on occasion, and she regularly keeps in
touch via phone and email with her family in Cagayan de Oro. However, overall she
describes her mood as sad most of the time.
What is Marisol experiencing?

WARNING: Criterion B

"The symptoms cause clinically

significant distress or impairment in
social, occupational, or other
important areas of functioning."

New York 2011
DSM-5 (page 31)
Neurodevelopmental What? Why? How?
Disorders
Neurodevelopmental Disorders
❖ Intellectual Disability (Intellectual Developmental
Disorder)
❖ Communication Disorders
❖ Autism Spectrum Disorder (ASD)
❖ Attentional-Deficit/Hyperactivity Disorder (ADHD)
❖ Specific Learning Disorder
❖ Motor Disorders
Intellectual Disability
(Intellectual Developmental Disorder)
Intellectual Disability: Criteria

❖ Deficits in intellectual functions (e.g., reasoning, problem solving,
planning, abstract thinking, academic learning, etc.)
❖ Assessment: IQ measures (typically 2 or more SDs below mean)
❖ Deficits in adaptive functioning (conceptual, social, practical domains)
❖ Assessment: clinical evaluations and objective measures (e.g., by
parent/caregiver, teacher, counselor)
❖ Onset during developmental period (childhood and adolescence)
❖ Some symptoms typically present before age 2
❖ ICD-10 coding based on severity: (F70) Mild, (F71) Moderate, (F72) Severe,
(F73) Profound
Intellectual Disability: Associated Features
London 2011
❖ Early signs (typically before
age 2): delays in motor
development, lack of age-
appropriate interest in
environmental stimuli, lack of
eye contact, less responsive to
voice and movement
❖ Co-occurring mental disorder:
increased risk for suicide
Intellectual Disability: Etiology*

Phenylketonuria (PKU) Down Syndrome

- recessive gene syndrome - extra chromosome 21 (trisomy 21)
- inability to metabolize amino acid in - 10-30% of moderate to severe cases
high-protein foods (detected at birth - physical: short, crooked fifth finger,
by blood test) slanted almond-shaped eyes, and
- if untreated: moderate to profound large protruding tongue
retardation, impaired motor and - health risks: heart lesions, respiratory
language development, and and intestinal defects and/or
unpredictable, erratic behaviors cataracts
- rapid aging: life expectancy below
normal, and higher risk for
Alzheimer's disease
*Not exhaustive list. For other etiology (e.g., Rett syndrome, San Phillippo syndrome,
etc.) see DSM-5 (page 38-39).
Intellectual Disability: Treatment
❖ PKU: may be prevented by diet

low in phenylalanine (found in
animal-based products, e.g.,
milk, meat)
❖ special education and training
(as early as infancy, i.e., early
intervention programs): social
skills training, behavioral
counseling Paris 2012
Intellectual Disability: ICD-10

❖ Still uses "mental retardation"
❖ IQ scores determine severity: mild (50-69), moderate (35-49),
severe (20-34), profound (under 20)
❖ Adaptive behavior is based on the following:
❖ minimal impairment of behavior
❖ significant impairment of behavior requiring treatment
❖ other impairments of behavior
❖ without mentation of impairment of behavior
Communication Disorders
❖ Language Disorder (DSM-IV: Expressive Language
Disorder + Mixed Receptive Expressive Language
Disorder) (new)
❖ Speech Sound Disorder (DSM-IV: Phonological
Disorder) (new)
❖ Childhood-Onset Fluency Disorder (DSM-IV:
Stuttering) (new)
❖ Social (Pragmatic) Communication Disorder (new)
Autism Spectrum Disorders

Autism Spectrum Disorders

Change Criteria:
❖ Autistic Disorder + Asperger's ❖ deficits in social
Disorder + Childhood communication and social

Disintegrative Disorder + interactions and
Pervasive Developmental ❖ restricted repetitive
Disorder NOS = Autism behaviors, interests, and

Spectrum Disorder activities (RRBs)
❖ Four separate disorders are
actually a single condition If no RRBs are present: Social
with different levels of Communication Disorder
severity in two core domains
Autism Spectrum Disorders: Criteria

Deficits in social communication and Restrictive, repetitive patterns of
social interactions across multiple behavior, interests, or activities, by at
contexts (currently or by history) least two of the following (currently or
by history), RRBs
- deficits in social/emotional
reciprocity (e.g., abnormal social - stereotyped or repetitive motor
approach, poor back-and-forth movements, use of objectives, or
conversation, reduced sharing of speech
interests, emotions or affect) - insistence on sameness, routine,
- deficits in nonverbal communicative rituals
behaviors (e.g., abnormal eye contact - highly restricted, fixated interests,
or body language, poor facial preoccupation/strong attachment
expressions) with unusual objects
- deficits in developing, maintaining, - hyper- or hyporeactivity to sensory
and understanding relationships aspects of environment
Autism Spectrum Disorders: Associated Features and Etiology
Associated Features Etiology

- hand-flapping, rocking, spinning are - structural brain abnormalities:
common smaller-than-normal cerebellum
- early signs (before age 2): lack of (motor control), enlarged ventricles
normal responsiveness to caregivers - abnormal levels of norepinepherine,
(e.g., refuse to cuddle, do not smile, serotonin, and dopamine
seem to look through others) - 50-100x higher in biological siblings
- poor outcome: 50% remain mute - higher concordance rates among
throughout life, 70% have IQ in MR identical twins
range - more common among males than
- best outcome: ability communicate females
verbally by age 5 or 6, IQ > 70, and
later onset of symptoms See DSM-5 (Table 2, page 52) for severity
guide (Level 1-3).
Asperger's & Autism: ICD-10

❖ Asperger's: retained in ICD-10
❖ Childhood Autism and Atypical Autism are differentiated from
each other
❖ Atypical Autism: pervasive developmental disorder that
differs based on age of onset or in a failure to fulfill all three
diagnostic criteria (reciprocal social interactions,
communication, or RRBs); often attributable to those with
profound or severe intellectual disability
❖ Remember: DSM-5 has only one category for all these diagnoses:
Autism Spectrum Disorder
Attention-Deficit/Hyperactivity
Disorder
Attention-Deficit/Hyperactivity Disorder (ADHD)
Highlights:
❖ Criteria is the same as DSM- ❖ symptoms prior to age 12
IV (DSM-IV: prior to age 7)

❖ Examples are included to ❖ comorbid diagnosis with
facilitate application across autism spectrum disorder

life span allowed
❖ Placed in the ❖ adults: cutoff of 5
neurodevelopmental symptoms, not 6 (as

disorder required for younger
persons)
ADHD: Criteria
❖ inattention: 6 or more symptoms for at least 6 months (age 17 or
older: at least 5 symptoms)
❖ hyperactivity and impulsivity: 6 or more symptoms for at least 6
months (age 17 or older: at least 5 symptoms)
❖ symptoms prior to age 12
❖ impairments in at least two settings (e.g., home, school, work)
❖ DSM-5 (ICD-10) coding based on specifier: 314.01 (F90.2) Combined
presentation, 314.00 (F90.0) Predominantly inattentive
presentation, 314.01 (F90.1) Predominantly hyperactive/impulsive
presentation
ADHD: Associated Features & Etiology


- test lower on IQ test though might - lower-than-normal activity in brain
have average or above average structures (caudate nucleus, globus
intelligence pallidus, and prefrontal cortex)
- academic difficulties common: likely - smaller-than-normal size of these
to be held back, suspended or structures
expelled from school - behavioral disinhibition hypothesis:
- few friends inability regulate behavior to fit
- peer rejection common situational demands
- fluctuation of symptoms in different - inability to regulate attention
settings (i.e., more likely in familiar, theory: difficulty inhibiting attention
highly repetitive, boring, or highly to non-relevant stimuli and focusing
structured situations, or where too intensely on certain stimuli to the
regular feedback is not available) exclusion of others
ADHD: Treatment
❖ psychopharm: Ritalin and other CNS stimulants (both

children and adults)
❖ behavioral: parent training in child behavioral
management or teacher training in classroom
management (e.g., positive reinforcement, time-out)
❖ Combined tx (psychopharm + behavioral tx) more
effective than either tx alone
Specific Learning Disorder

Los Angeles 2013
❖ Reading Disorder +
Mathematics Disorder +
Disorder of Written Expression
+ Learning Disorder NOS =
Specific Learning Disorder
❖ Specifiers for each deficit is
included: e.g., 315.00 (F81.0)
with impairment in reading
Review Questions
Review
❖ In the DSM-IV-TR, a diagnosis of Mental Retardation
requires an IQ test score that is at least _____ below
the mean.
❖ A. 1.5 standard deviations (SDs)
❖ B. 1 SD
❖ C. 2 SDs
❖ D. 3 SDs
Review
❖ True or False. Both the DSM-IV-TR and the DSM-5

require an IQ test score of at least 2 SDs.
Review
❖ In the DSM-5 the diagnosis of Intellectual Disability

may be specified by severity based on:
❖ A. IQ score
❖ B. adaptive functioning
❖ C. age of onset
❖ D. none of the above
Review
❖ A child exhibits severe impairments in social
functioning and a restricted range of interests.
However, her language, cognitive, and self-help skills
are similar to those of peers of the same age.
❖ In the DSM-IV-TR, these symptoms are consistent with
which disorder?
❖ In the DSM-5 these symptoms are consistent with which
disorder?
Review
❖ The best prognosis for Autistic Disorder (DSM-IV-TR)
or Autism Spectrum Disorder (DSM-5) is associated
with:
❖ A. female gender
❖ B. precipitating factor
❖ C. verbal communication skills by age 5 or 6
❖ D. normal adaptive functioning
Review
❖ What is Tourette's Disorder?

Review
❖ A person with Tourette's Disorder is most likely to

also have which of the following?
❖ A. depressed mood
❖ B. an eating disorder
❖ C. aphasia and acalculia
❖ D. obsessions and compulsions
Review
❖ Which of the following best describes ADHD in adults?
❖ A. Hyperactivity becomes less prominent while impulsivity
and inattention stay the same or become more prominent.
❖ B. Impulsivity becomes less prominent while hyperactivity and
inattention stay the same or become more prominent.
❖ C. Inattention becomes less prominent while hyperactivity and
impulsivity stay the same or become more prominent.
❖ D. Hyperactivity and impulsivity become less prominent while
inattention stays the same or becomes more prominent.
Review
❖ A child with a Specific Learning Disorder is most

likely to also receive a diagnosis of:
❖ A. OCD
❖ B. Enuresis
❖ C. Mental Retardation/Intellectual Disability
❖ D. ADHD
Review
❖ Which of he following is not an early sign of mental

retardation/intellectual disability?
❖ A. lack of eye contact
❖ B. less responsive to voice and movement
❖ C. delays in motor development
❖ D. seem to look through others
Paris 2012
DSM-5 (page 87)
Schizophrenia Spectrum & What? Why? How?

Other Psychotic Disorders
Schizophrenia Spectrum & Other Psychotic Disorders
❖ Schizophrenia
❖ Schizoaffective Disorder
❖ Delusional Disorder
❖ Catatonia
Note on Terminology: Psychotic Disorders
❖ Delusions
❖ Hallucinations
❖ Disorganized Thinking (Speech)
❖ Grossly Disorganized or Abnormal Motor Behavior
(including Catatonia)
❖ Negative Symptoms
What are delusions?

Delusions
Fixed beliefs that are not amenable to change in light of conflicting
evidence; content may vary:
❖ persecutory: one is going to be harmed, harassed (most common)
❖ referential delusions: gestures, comments, environmental cues, etc., are
directed at oneself
❖ grandiose delusions: having exceptional abilities, wealth, or fame
❖ erotomanic delusions: falsely believing that another person is in love with
him/her
❖ nihilistic delusions: believing that a major catastrophe will happen
❖ somatic delusions: preoccupations regarding health and organ function
What are hallucinations?

Hallucinations
Perception-like experiences that occur without an external
stimulus
❖ vivid and clear, with the full force and impact of normal
perceptions (i.e., the experience appears very real)
❖ not under voluntary control
❖ may occur in any sensory modality (auditory
hallucination most common, typically voices independent
from the person and that may or may not be familiar to the
person)
What is disorganized thinking

(speech)?
Disorganized Thinking (Speech)

Formal thought disorder that is typically inferred from
the person's speech
❖ derailment or loose association: switch from one topic
to another
❖ tangentiality: answers are somewhat related or
completely unrelated to questions being asked
❖ incoherence or "word salad": nearly incomprehensible
speech, resembling receptive aphasia
What is grossly disorganized or abnormal

motor behavior (including catatonia)?
Grossly Disorganized or
Abnormal Motor Behavior (including Catatonia)
Behaviors ranging from childlike "silliness" to unpredictable

agitation, most evident in goal-directed behavior
Catatonia: marked decreased in reactivity to the environment
❖ negativism: resistance to instructions
❖ mutism and stupor: rigid, inappropriate or bizarre posture;
complete lack of verbal and motor responses
❖ catatonic excitement: purposeless and excessive motor
activity without obvious cause
What are negative symptoms?

Negative Symptoms
❖ diminished emotional expression: reductions in expression of emotions in the
face, eye contact, intonation of speech (prosody), and movements of hand,
head, and face relative to emotional content of speech
❖ avolition: decrease in motivated, self-initiated purposeful activities (e.g.,
sitting for a long time)
❖ alogia: diminished speech output
❖ anhedonia: decreased ability to experience pleasure from positive stimuli
❖ asociality: lack of interest in social interactions
Negative symptoms account for a significant portion of morbidity of those
with schizophrenia and are less common among other types of psychotic
disorders.
Schizophrenia
Schizophrenia
Why: poor reliability in distinguishing
Change #1: Elimination of bizarre
between bizarre and non-bizarre
delusions
delusions
Change #2: At least 1 of 2 required Why: (a) to improve reliability and (b)
symptoms in Criterion A must be to prevent individuals with only
delusions, hallucinations, or negative symptoms and catatonia from
disorganized speech being diagnosed with schizophrenia
Change #3: Subtypes (e.g., paranoid, Why: limited diagnostic stability, low
disorganized, catatonic, etc.) are reliability, poor validity; instead:
eliminated dimensional rating severity
Schizophrenia: Associated Features

❖ no evidence linked to violence/aggression; most psychotic
individuals are not violent/aggressive
❖ onset: male (early to mid-20s), female (late 20s); earlier onset is
predictor of worse prognosis; onset prior to adolescence is rare
❖ suicide risk: 5-6% die by suicide, 20% attempt suicide
❖ prognosis: usually chronic, complete remission is rare; positive sxs
decrease over time; negative sxs increase over time
❖ better prognosis: positive premorbid adjustment, acute and late
onset, female gender, precipitating event, insight, family h/o mood
dx, no family h/o schizophrenia
Schizophrenia: Etiology
❖ enlarged ventricles in most patients
❖ possible types: Type 1 (positive sxs, good premorbid
functioning, favorable responses to meds, due to
neurotransmitter abnormalities), Type 2 (negative sxs,
poor premorbid adjustment, poor response to meds,
due to structural brain abnormalities)
❖ abnormal levels in dopamine, norepinephrine, or
serotonin
Schizophrenia: Treatment
❖ antipsychotics
❖ traditional/typical (e.g., haloperidol): useful for positive
symptoms but severe risk for tardive dyskinesia (TD)
❖ 2nd generation/atypical (e.g., clozapine): useful for
negative symptoms, less risk for TD
❖ family intervention: target high-EE (expressed emotion: open
criticism, hostile; or overprotective, symbiotic)
❖ other interventions: social skills training, supported
employment
Schizoaffective Disorder, Delusional Disorder & Catatonia
Schizoaffective Disorder: major mood

Why: to improve reliability, diagnostic
episode must be present for the
stability, and validity
majority of the total duration
Delusional Disorder: (a) non-bizarre

Why: to improve reliability, diagnostic
delusion no longer required and (b) no
stability, and validity; instead:
longer separated from shared
specifiers for bizarre type delusions
delusional disorder
Catatonia: (a) criteria is the same

whether context is psychotic, bipolar, Why: to improve reliability, diagnostic
depression, etc. and (b) requires 3 stability, and validity
symptoms from a total of 12
Schizophrenia: ICD-10
The DSM subgroupings of schizophrenia (whether in the IV-TR or 5) has
always differed from the ICD
The ICD include the following subgroups:
❖ Paranoid schizophrenia Residual schizophrenia
❖ Hebephrenic schizophrenia (disorganized) Simple Schizophrenia
❖ Catatonic schizophrenia Other Schizophrenia
(DSM:5 Schizophreniform)
❖ Undifferentiated schizophrenia Schizophrenia, unspecified
(DSM-5: Schizophrenia)
❖ Post-schizophrenic depression
What are the differences among

Brief Psychotic Disorder,
Schizophreniform Disorder,
Schizophrenia, and Schizoaffective
Disorder?
Review Questions
Review
❖ Schizophrenia has been linked to several structural

abnormalities, with the most consistent finding being:
❖ A. larger-than-normal prefrontal lobes
❖ B. enlarged hippocampus
❖ C. enlarged ventricles
❖ D. smaller-than-normal cerebellum
Review
❖ For individuals with Schizophrenia, the poorest prognosis is
associated with:
❖ A. female gender, younger age at onset, and predominant negative
symptoms
❖ B. female gender, older age at onset, and predominant positive
symptoms
❖ C. male gender, younger age at onset, and predominant negative
symptoms
❖ D. male gender, older age at onset, and predominant positive
symptoms
Review
❖ A 34-year-old woman is convinced that her boss is in
love with her despite the fact that there is no evidence
to support her belief. The woman's belief is most
suggestive of which of the following?
❖ A. erotomanic delusion
❖ B. grandiose delusion
❖ C. delusions of reference
❖ D. illusion
Review
❖ Better prognosis is associated with the following

except:
❖ A. female gender
❖ B. early onset
❖ C. family h/o mood disorder
❖ D. positive premorbid adjustment
Review
❖ In the treatment of psychotic disorders, which of the
following medications are more helpful in reducing
the negative symptoms?
❖ A. first-generation/typical antipsychotics
❖ B. second-generation/atypical antipsychotics
❖ C. SSRIs
❖ D. MAOIs
Review
❖ Which of the following ICD-10 subgroups most
closely resembles the DSM-5 conceptualization of
Schizophrenia?
❖ A. Schizophrenia, unspecified
❖ B. Paranoid Schizophrenia
❖ C. Undifferentiated Schizophrenia
❖ D. Other Schizophrenia
Review
❖ Which of the following best distinguishes Schizophreniform
Disorder from Schizophrenia?
❖ A. Schizophreniform is less than 1 month; Schizophrenia, 6 months
or more
❖ B. Schizophreniform is 6 months or more; Schizophrenia, less than 6
months
❖ C. Schizophreniform is at least 1 month but less than 6 months;
Schizophrenia is 6 months or more
❖ D. Shizophreniform is less than 1 month; Schizophrenia, less than 6
months
Bohol 2012
DSM-5 (page 123)
Bipolar & Related What? Why? How?
Disorders
Bipolar & Related Disorders
❖ Bipolar Disorder
❖ Other Specified Bipolar and Related Disorder
Note on Terminology: Bipolar Disorders
❖ Manic Episode
❖ Hypomanic Episode
❖ Major Depressive Episode
What is mania?
Mania
❖ abnormally and persistently elevated, expansive, or irritable mood
❖ abnormally and persistently increased goal-directed activity or
energy
❖ other symptoms: increased self-esteem or grandiosity; decreased
need for sleep; more talkative than usual or pressure to keep
talking; flight of ideas or subjective experience that thoughts are
racing; distractibility; increase in goal-directed activity or
psychomotor agitation; excessive involvement in activities that
have a high potential for painful consequences (e.g., buying
sprees, sexual indiscretions)
What are two distinct differences between

a manic episode and a hypomanic episode?
Manic & Hypomanic Episodes

Manic Episode Hypomanic Episode

- duration: at least 1 week - duration: at least 4 days

- severity: sufficiently severe to cause - severity: not severe enough to cause
significant impairment in social or impairment in social or occupational
occupational functioning or to functioning or to necessitate
necessitate hospitalization to prevent hospitalizations. If there are
harm to self or others, or there are psychotic features, the episode, by
psychotic features definition, is manic.
Bipolar I & Bipolar II Disorders

Bipolar I Bipolar II

- at least one manic episode - at least one hypomanic episode

- may be preceded or followed by - must have current or past h/o
hypomania and/or major major depressive episode
depressive episode
- no h/o manic episode
Bipolar I Disorder: Associated Features & Etiology

- onset: approximately 18 years of age - family h/o bipolar disorder: strongest
- more than 90% of individuals who and most consistent risk factor
have a single manic episode go on to - separated, divorced, or widowed
have recurrent mood episodes (major individuals have higher rates than do
depressive, manic, or hypomanic) individuals who are married or have
- approximately 60% of manic episodes never been married
occur immediately before a major - gender-related risks (female): more
depressive episode likely to have rapid cycling and
- "rapid cycling": four or more mood mixed states, more likely to
episodes within 1 year experience depressive symptoms,
- suicide risk: at least 15x higher higher risk of alcohol use disorder
compared to the general population;
bipolar accounts for 25% of all
completed suicides
Bipolar I Disorder: Treatment

❖ pharmacotherapy (medication),
especially Lithium
❖ Lithium: effective in 60-90% of
cases, prevents mood swings
❖ compliance issues: feel better,
meds are "not necessary,"
unwillingness to "give up
high" (mania), severe side effects
(e.g., hand tremor, increased thirst,
diarrhea, vomiting, weight gain)
❖ most effective tx: meds +
Kyoto 2006
psychotherapy
Bipolar & Related Disorder

Change #1: Mania/Hypomania Change #2: Mixed Episode

Addition to Criterion A: No more mixed episode

"...and abnormally and persistently Now a specifier: "with mixed features"
increased goal-directed activity or
energy." hypomanic mania + 3/6 major
depressive symptoms
Why: to improve accuracy of diagnosis
and facilitate earlier detection in clinical OR
settings
major depressive symptoms + 3/7
manic symptoms
Review Questions
Review
❖ Anita, age 16, is brought to therapy by her mother who says the girl has recently
become "another person." She says that Anita used to be friendly and
cooperative and popular at school. However, for the last few weeks, she has
been constantly irritable and argumentative, is not doing her homework and
has failed several tests, and has been getting very little sleep. When the
therapist interviews Anita, her speech is loud and rapid, and she is easily
distracted. He learns that she has started drinking alcohol and has engaged in
high-risk sexual behavior. The most likely diagnosis for Anita is:
❖ A. Conduct Disorder
❖ B. ADHD
❖ C. Bipolar II Disorder
❖ D. Bipolar I Disorder
Review
❖ Rapid cycling is defined as how many mood swings in

a year?
❖ A. 2 or more in a year
❖ B. 3 or more in a year
❖ C. 4 or more in a year
❖ D. 5 or more in a year
Review
❖ True or False. In Cyclothymic Disorder, for at least 2

years (at least 1 year in children and adolescents) there
have been numerous periods with hypomanic
episodes and numerous periods with depressive
episodes.
Review
❖ ADHD must be distinguished from Bipolar
symptoms. Which of the following ADHD symptoms
do not typically overlap with Bipolar symptoms?
❖ A. rapid speech
❖ B. less need for sleep
❖ C. distractibility
❖ D. increased goal-directed activity
Review
❖ Individuals with Bipolar Disorder might show mood
lability and impulsivity. These symptoms are common
in which of the following personality disorders?
❖ A. Avoidant Personality Disorder
❖ B. Borderline Personality Disorder
❖ C. Schizoid Personality Disorder
❖ D. Antisocial Personality Disorder
Beijing 2005
DSM-5 (page 155)
Depressive What? Why? How?
Disorders
Depressive Disorders
❖ Major Depressive Disorder

❖ Disruptive Mood Dysregulation Disorder (new)
❖ Premenstrual Dsyphoric Disorder (new)
❖ Persistent Depressive Disorder (Dysthymia) (renamed)
What is a
major
depressive
episode?
Major Depressive Disorder

❖ No major changes: (a) similar core criterion symptoms and (b) similar
duration of 2 weeks
❖ "Bereavement exclusion" removed. Why?
1. to remove the implication that bereavement only lasts 2 months
2. to recognize that bereavement is a significant stressor that can
lead to depression
3. to acknowledge that it is a risk factor for individuals with past
personal or family histories of depression
4. to acknowledge that psychosocial and medication treatments
have similar effects compared to those who are non-bereaved
Major Depressive Disorder: Associated Features
❖ onset: at any age, with peak incidence at early to mid-20s

❖ prevalence: equal for men and women (prior to puberty);
women 2x than men in adolescence through adulthood
❖ 5-10% develop manic episode
❖ Kindling Model: the more past episodes, the higher risk
for future episodes
❖ suicide risk: high mortality accounted by suicide
Major Depressive Disorder: Etiology

❖ genetics: family h/o depression (w/ heritability at about
40%); concordance: .50 (monozygotic twins), .20 (dizygotic
twins)
❖ neurotransmitters
❖ catecholamine hypothesis: norepinephrine deficiency
❖ indolamine hypothesis: low serotonin levels
❖ elevated cortisol levels ("stress hormones")
❖ low new cell growth in brain
Major Depressive Disorder: Etiology (Cont'd)
❖ Cognitive-Behavioral Theories
❖ low response-contingent reinforcement (Lewinsohn, 1974)
❖ learned helplessness/sense of hopelessness: attributing
negative events to internal, stable, and global factors
(Seligman et al., 1978)
❖ self-control model: problems w/ self-monitoring, self-
evaluations, self-inforcement (Rehm et al., 1987)
❖ depressive cognitive triad: negative, illogical self-
statements about oneself, world, and future (Beck)
Major Depressive Disorder: Treatment

Do If
"classic" depression: vegetative (bodily)
tricyclics (TCAs) sxs, worse sxs in morning, acute onset,
short duration, moderate sxs
selective serotonin reuptake inhibitors melancholic depression; fewer side

(SSRIs) effects than TCAs
atypical sxs (e.g., phobic features, panic

monoamine oxidase inhibitors (MAOIs) sxs), hypersomnia, worsening sxs in
late day
CBT, Interpersonal Therapy, vs CBT more effective for reducing

Imipramine (a TCA) (NIMH study) relapse
Major Depressive Disorder: ICD-10

❖ DSM-5 and ICD-10 very similar, except ICD-10 includes reduced
energy as one of the primary sxs (i.e., in addition to depressed
mood and loss of interest/enjoyment)
❖ ICD-10 does not endorse atypical sxs (increased appetite,
hypersomnia) but supports diminished appetite and disturbed
sleep
❖ ICD-10: self-harm and suicide action as sxs (whereas DSM-5
endorses recurrent thoughts of death as threshold)
❖ ICD-10: bleak and pessimistic views of the future (Remember:
cognitive triad by Beck)
...pause here.
Schizophrenia Spectrum & Other

Psychotic Disorders..................87

Bipolar & Related Disorders....123

Depressive Disorders..............155
Why are these disorders next to

each other?
Review Questions
Review
❖ Which of the following is true about the prevalence of
Major Depressive Disorder in adolescents and adults?
❖ A. The rates for males and females are about equal.
❖ B. The rate for females is about twice the rate for males.
❖ C. The rate for males is about twice the rate for females.
❖ D. The rate for females is about three and one-half times
the rate for males.
Review
❖ The behavioral model (Lewinsohn's) model of
depression attributes the illness to:
❖ A. internal, stable, and global attributions for negative
life events
❖ B. inadequate stimulus discrimination
❖ C. emotional dysregulation
❖ D. a low rate of response-contingent reinforcement
Review
❖ Every rainy season Emil struggles to find work as a day laborer. He is married
and a father of three young children. His wife does not work and cares for their
children. During the rainy seasons, when he is typically unemployed, he feels
inadequate. He describes his mood as low most days during this period of
unemployment. He sleeps a lot, has trouble concentrating, and loses his
appetite. He feels that he has failed as a husband and father. If Emil is
diagnosed with a Major Depressive Disorder, which specifier, if any, is most
consistent with his presenting problems?
❖ A. with melancholic features
❖ B. with peripartum onset
❖ C. with seasonal pattern
Suicide (in the U.S.):

A Closer Look
What are some factors associated

with high risk for suicide?
Suicide: High Risk Factors

History
❖ 60-80% of people who commit suicide have made at
least one previous attempt
❖ 80% give a definite warning of their intention
Age
❖ higher for adults than for children and adolescents
❖ highest (typically) for those ages 65 and older
Gender
❖ 4-5x as many males commit suicide as females, BUT
❖ females attempt suicide 2-3x more often than males
Why are males more likely to kill

themselves even though females are
more likely to attempt suicide?
Gender
❖ 4-5x as many males commit suicide as females, BUT
❖ females attempt suicide 2-3x more often than males
❖ Males tend to use more lethal methods (gun, hanging,
carbon monoxide)
❖ Females are more likely to use drugs

Race
❖ Suicide rates are highest for Whites/Caucasians (of all ages), EXCEPT
❖ American-Indian/Alaskan Native adolescents and young adults (ages
15-34): 1.9x higher than the U.S. national average for that age group
Marital Status
❖ Divorced, separated, widowed people have highest rates; followed by
those who are single; lowest rate among married
Cognitive Correlates
❖ Hopelessness has been found to be more predictive of suicide than the
intensity of depressive symptoms

Life Stress
❖ failure at work or school, rejection by a loved one, living alone, absence of social
support/social ties
❖ adolescents: completed suicide is often immediately preceded by an interpersonal
conflict (e.g., rejection by boyfriend/girlfriend or argument w/ parent)
Earning Warning Signs
❖ adolescents: talking about death, talking about a reunion w/ a deceased person,
giving away prized possessions
Psychiatric Disorders
❖ most common: Major Depressive Disorder and Bipolar
❖ 50-80% of suicidal individuals have a h/o severe depression

Biological Correlates
❖ low serotonin levels and 5HIAA (a serotonin metabolite)
Suicide Attempters
❖ more likely to be female, under 35, use drug overdose/other non-lethal
methods, make attempt in setting that provides high chance for rescue
Suicide Helplines
❖ most frequent caller: White/Caucasian females
❖ reasons: depression (adult callers), interpersonal conflicts (adolescent
callers)
Suicide: Clinical Intervention

❖ use direct questions: e.g., Have you ever thought that life is
not worth living? Have you ever thought of hurting yourself?
❖ assess for risk of suicide: see high risk factors, including possible
need for hospitalization
❖ if no hospitalization: (a) maintaining a no-suicide contract
(research is mix on this), (b) providing 24-hour clinical back-up
(e.g., emergency phone numbers), (c) using strategies to
increase compliance w/ tx (e.g., actively pursuing no-shows,
involving family/friends), and (d) making sure firearms have
been removed from the home
Review Questions
Review
❖ Which of the following individuals is at greatest risk

for completed suicide?
❖ A. a 70-year-old widowed male
❖ B. a 30-year-old divorced female
❖ C. a 24-year-old single male
❖ D. a 55-year-old married female
Review
❖ Which of the following is most predictive of suicide?

❖ A. intense low mood
❖ B. hopelessness
❖ C. worthlessness
❖ D. impulsivity
Review
❖ The lowest rates of suicide are found in which of the

following groups?
❖ A. divorced
❖ B. single
❖ C. married
❖ D. widowed
Review
❖ Suspicion that a patient is at risk for suicide should be

immediately addressed through the use of _____.
❖ A. open-ended questions
❖ B. closed questions
❖ C. direct questions
❖ D. derogatory questions
Review
❖ True or False. Asking someone about suicide (e.g.,

their thoughts, plan, intention) increases their risk of
attempting suicide.
Beijing 2005
DSM-5 (page 189)
Anxiety Disorders What? Why? How?

Anxiety Disorders
❖ Agoraphobia, Specific Phobia, Social Anxiety Disorder (Social Phobia)
❖ Panic Attack
❖ Panic Disorder and Agoraphobia
❖ Specific Phobia
❖ Social Anxiety Disorder (Social Phobia)
❖ Separation Anxiety Disorder
❖ Selective Mutism
❖ Obsessive-Compulsive Disorder (new chapter)
❖ Posttraumatic Stress Disorder (new chapter)
Agoraphobia, Specific Phobia and Social Anxiety Disorder
Over age 18: Do not have to recognize that their anxiety is excessive of
unreasonable
Why: (a) overestimation of danger in "phobic" situations and (b) among older
individuals: misattribution of "phobic" fears to aging
Anxiety must be out of proportion to the actual

danger or threat in the situation
6-month duration: Now extended to all ages (DSM-IV: limited to those under
age 18).
Anxiety Disorders
Panic Disorder and Agoraphobia: No
longer linked, two separate disorders Why: substantial number of individuals
(i.e., no more "with agoraphobia," with agoraphobia do not experience
"without agoraphobia," or "without panic symptoms
history of agoraphobia")
Why: previous specifiers (i.e.,

Panic Attack: (a) similar features as
situationally bound/cued, situationally
DSM-IV but (b) specifiers replaced with
predisposed, and unexpected/uncued)
"expected" or "unexpected"
were too complex and confusing
Why: (a) "fears include most social

Social Anxiety Disorder: (a)
situations" (DSM-IV) difficult to
"generalized" specifier is deleted and
operationalize and (b) performance
(b) replaced with "performance only"
fears appear to be distinct subset
Agoraphobia: ICD-10
❖ ICD-10 still differentiates Agoraphobia with Panic

(F41.0) and Without Panic (F40.0).
Note on Terminology: Panic Disorder
❖ Panic attack
What is a panic attack?

Panic Attack
Abrupt surge of intense fear or intense discomfort that reaches a peak
within minutes; other symptoms include:
❖ palpitations, pounding heart, or accelerated heart rate
❖ sweating
❖ trembling or shaking
❖ sensations of shortness of breath or smothering
❖ feelings of choking
❖ chest pain or discomfort
❖ nausea or abdominal distress
Panic Attack (Cont'd)

❖ feeling dizzy, unsteady, light-headed, or faint
❖ chills or heat sensations
❖ paresthesias (numbness or tingling sensations)
❖ derealization (feeling of unreality) or depersonalization (being detached
from one-self)
❖ fear of losing control or "going crazy"
❖ fear of dying
❖ Culture-specific symptoms (e.g., tinnitus, neck soreness, headache,
uncontrollable screaming or crying) are common but should not count as
one of the required symptoms for diagnosis.
Panic Disorder: Treatment

Bangkok 2006
❖ in vivo exposure with response
prevention (flooding)
❖ supplemented w/ cognitive tx,
relaxation, breathing
retraining, and medication
❖ medication: TCAs, SSRIs,
benzodiazapines,
anticonvulsants (30-70%
relapse if meds alone)
Anxiety Disorders
Separation Anxiety Disorder Selective Mutism

❖ Now an anxiety disorder ❖ Now an anxiety disorder
(DSM-IV: infant, childhood (DSM-IV: infant,
or adolescent category) childhood or adolescent
❖ No longer specified that age category)
of onset must be before 18 ❖ Why: large majority of
years children with selective
❖ Adult criterion: duration mutism are anxious
lasting at least 6 months or ❖ DSM-5 symptoms are
more unchanged
Separation Anxiety Disorder: ICD-10
❖ In ICD-10 Separation Anxiety Disorder remains under

the section for Behavioral and Emotional Disorders with
onset usually occurring in childhood and adolescence.
❖ There are no elaborations on exceptions made for
adults. The diagnosis should not be used unless "it
constitutes an abnormal continuation of
developmentally appropriate separation anxiety."
Specific Phobia & Social Phobia: Etiology

Specific Phobia Social Phobia

- Two-Factor Theory: avoidance - neurotransmitters: abnormalities in
conditioning of classical (Pavlov) and serotonin, dopamine, and
operant (Skinner) conditioning norepinephrine level

- Social Learning Theory: vicarious - cognitive (information processing
learning of excessive anxiety and bias): selectively attending to
avoidance behaviors by observing socially threatening stimuli and
caregivers/parents overestimating the likelihood for
negative outcomes
Specific Phobia & Social Phobia: Treatment

Specific Phobia Social Phobia

- in vivo exposure with response - exposure
prevention (flooding)
- social skills training
- cognitive self-control: relaxation
techniques, visualization of pleasant - cognitive techniques
scene, positive self-statement
- medication: antidepressants, beta-
blocker (e.g., propranolol)
Review Questions
Review
❖ Which of the following disorders from Anxiety
Disorders has been removed from the section and
placed in its own chapter?
❖ A. Selective Mutism
❖ B. Obsessive-Compulsive Disorder
❖ C. Separation Anxiety Disorder
❖ D. Social Phobia
Review
❖ True or False. In the treatment of Panic Disorder, the

use of medication (e.g., TCAs, benzodiazapines) is
typically sufficient to prevent relapse.
Review
❖ True or False. Selective mutism occurs across a

number of conditions, with or without social
interactions, whereas a communication disorder (e.g.,
language disorder, speech sound disorder) typically
occurs where there is a demand to speak (e.g., a
classroom).
Review
❖ Maria is a 21-year-old UP student. She has an intense fear of riding the
jeepney to class. Her dread typically starts when she is waiting in a long
line. When she sees the jeepney arriving, her fear intensifies. She sweats
profusely, feels her heart racing, and her knees shaking. She wants to
avoid using the jeepney, but it is the most convenient and accessible way
to get to her class. The taxi would be too costly. Based on the DSM-5,
Maria is likely experiencing which of the following:
❖ A. Agoraphobia
❖ B. Specific Phobia, Situational
❖ C. Social Anxiety Disorder (Social Phobia)
❖ D. Panic Disorder without Agoraphobia
Review
❖ True or False. In the DSM-IV-TR, Separation Anxiety

Disorder only applied to those under 18 years of age.
Hong Kong 2009
DSM-5 (page 235)
Obsessive Compulsive What? Why? How?
& Related Disorder

Obsessive-Compulsive & Related Disorder
❖ Specifiers for Obsessive-Compulsive and Related

Disorders
❖ Body Dysmorphic Disorder
❖ Hoarding Disorder (new)
❖ Trichotillomania (Hair-Pulling Disorder) (renamed)
❖ Excoriation (Skin-Picking) Disorder (new)
Obsessive-Compulsive & Related Disorders

Why: (a) to emphasize that people
might present with a range of insight
"with poor insight" (DSM-IV): now into their disorder and (b) to minimize
good or fair insight, poor insight, and the diagnosis of schizophrenia
absent insight/delusional spectrum/other psychotic disorder for
individuals with absent insight/
delusional symptoms
Why: to reflect growing evidence on
Body Dysmorphic Disorder: addition
diagnostic validity and clinical utility of
of "with muscle dysmorphia" specifier
making this distinction
(a) body-focused repetitive behavior,

Other Specified and Unspecified
other than hair-pulling and skin-
Obsessive-Compulsive and Related
picking (e.g., nail biting)
Disorders
(b) obsessional jealousy (nondelusional)
Note on Terminology:
Obsessive-Compulsive & Related Disorders
❖ Obsessions
❖ Compulsions
❖ Hoarding
What are obsessions?

Obsessions
❖ Recurrent and persistent thoughts, urges, or images
that are experiences, at some time during the
disturbance, as intrusive and unwanted, and that in
most individuals cause marked anxiety or distress,
AND
❖ The individual attempts to ignore or suppress such
thoughts, urges, or images, or to neutralize them with
some other thought or action (i.e., by performing a
compulsion)
What are compulsions?

Compulsions
❖ Repetitive behaviors (e.g., hand washing, ordering,
checking) or mental acts (e.g., praying, counting, repeating
words silently) that the individual feels driven to perform
in response to an obsession or according to rules that must
be applied rigidly, AND
❖ The behaviors or mental acts are aimed at preventing or
reducing anxiety or distress, or preventing some dreaded
event or situation; however, these behaviors or mental acts
are not connected in a realistic way with what they are
designed to neutralize or prevent, or are clearly excessive
What is hoarding?
Hoarding
❖ Persistent difficulty discarding or parting with
possessions, regardless of their actual value
❖ This difficulty is due to a perceived need to save the
items and to distress associated with discarding them
❖ The difficulty discarding possessions results in the
accumulation of possessions that congest and clutter
active living areas and substantially compromises their
intended use.
OCD: Associated Features

❖ Most have good/fair insight, some have poor insight, a few (4% or less) have
absent insight/delusional beliefs
❖ Up to 30% of individuals with OCD have a lifetime tic disorder (most common in
males with onset of OCD in childhood)
❖ Equally common in males and females, though earlier onset is more common in
males (25% of males: before age 10)
❖ Age of onset: around 19-20, w/ 25% of cases starting by age 14
❖ Compulsions are more easily diagnosed in children than obsessions are because
compulsions are observable. However, both compulsions and obsessions are
common in most children.
❖ In addition to clinically significant distress or impairment, obsessions and
compulsions might be time-consuming
OCD: Etiology & Treatment

Etiology Treatment

- temperamental: greater internalizing - exposure w/ response prevention
symptoms, higher negative (e.g., though stopping)
emotionality, and behavioral
inhibition - medication: tricyclic clomipramine,
SSRIs
- environmental: trauma or stressful
events

- genetic: family h/o OCD

- brain: low serotonin levels,
orbitofrontal cortex, anterior
cingulate cortex, and striatum
...pause here.
Pop Quiz
What is the difference between

OCD and Obsessive Compulsive
Personality Disorder (OCPD)?
Three Key Differences
❖ In OCPD there are no obsessions or compulsions.

❖ In OCPD there is a preoccupation w/ orderliness,
perfectionism, and control.
❖ In OCPD, if there are rituals, the rituals are related to
perfectionism, not to reduce anxiety or distress as in
OCD.
Hoarding Disorder: In Brief

❖ Equally common among males and females, but probably more
common among males
❖ More prevalent in older adults (55-94) compared with younger
adults (34-44)
❖ Hoarding sxs may first emerge around 11-15 years of age
❖ Etiology: temperamental (indecisiveness), environmental (trauma or
stressful event), genetic (family h/o hoarding, 50% have family
members w/ hoarding)
❖ Comorbidity: MDD (50% of cases), social phobia, and generalized
anxiety; OCD (20%)
Trichotillomania: In Brief
❖ Criteria: (a) recurrent pulling out of one's hair, resulting in hair loss, (b)
repeated attempts to decrease or stop hair pulling
❖ Range of behaviors or rituals: particular kind of hair to pull, specific
way of pulling out hair, closely examining the hair after pulling
❖ Variable emotions: triggers by feelings of anxiety or boredom, tension,
gratification/relief/pleasure
❖ Variable awareness: more focused attention, more automatic
❖ Hair pulling typically done alone or w/ immediate family members,
not in the presence of others
❖ Other common behaviors: skin picking, nail biting, lip chewing
Trichotillomania: In Brief (Cont'd)
❖ More common in females, at a ratio of approximately

10:1
❖ Onset: typically coincides with or follows puberty
❖ Course: typically chronic, complete remission is rare
(though sxs may come and go for weeks, months, or
years)
Excoriation: In Brief
❖ Criteria: (a) recurrent skin picking resulting in skin lesions, (b)
repeated attempts to decrease or stop skin picking
❖ Most common sites: face, arms, and hands (typically using the fingers)
❖ Range of behaviors or rituals: search for a particular scab, lesion, etc.;
may examine, play with, or mouth or swallow the skin
❖ Various emotional states: anxiety, boredom, tension, gratification/
pleasure/relief
❖ More common in females (up to 75%)
❖ More common in those w/ OCD
Review Questions
Review
❖ The rates of Obsessive-Compulsive Disorder:
❖ A. are higher for males in childhood but about equal for
males and females in adulthood
❖ B. are higher for females in childhood but about equal
for males and females in adulthood
❖ C. are about equal for males and females throughout the
lifespan
❖ D. are higher for females throughout the lifespan
Review
❖ Which of the following statements is the most accurate?
❖ A. Hoarding is probably more common in males;
trichotillomania and excoriation, more common in females
❖ B. Hoarding is probably more common in females;
trichotillomania and excoriation, more common in males
❖ C. Hoarding and trichotillomania are more common in
males; excoriation, more common in females
❖ D. All are more common in females.
Review
❖ True or False. Muscle dysmorphia is a specifier only

for males with Body Dysmorphic Disorder.
Bohol 2012
DSM-5 (page 265)
Trauma- and Stress- What? Why? How?
Related Disorders
Trauma- and Stressor-Related Disorders
❖ Acute Stress Disorder

❖ Adjustment Disorder
❖ Posttraumatic Stress Disorder
❖ Reactive Attachment Disorder
❖ Disinhibited Social Engagement Disorder
Reactive Attachment: In Brief

❖ Criteria: (a) pattern of inhibited, emotionally
withdrawn behavior toward adults, (b) persistent social
and emotional disturbance (e.g., limited positive affect,
minimal social and emotional responsiveness, and (c)
child has experienced a pattern of extremes of
insufficient care (e.g., social neglect, repeated changes
of primary caregivers)
❖ Evident before age 5
Disinhibited Social Engagement: In Brief
❖ Criteria: (a) pattern of behavior in which a child actively approaches and

interacts with unfamiliar adults
❖ reduced or absent reticence in approaching and interacting with
unfamiliar adults
❖ overly familiar verbal or physical behavior
❖ diminished or absent checking back with adult caregiver after
venturing away
❖ willing to go off with an unfamiliar adult with minimal or no hesitation
❖ (b) child has experienced a pattern of extremes of insufficient care (e.g., social
neglect, repeated changes of primary caregivers)
What is similar about reactive attachment

and disinhibited social engagement?
Social neglect: the absence of

adequate caregiving during
childhood

This is a diagnostic requirement for

both Reactive Attachment Disorder
and Disinhibited Social Engagement.
If both have similar etiology, why

the differences in manifestation?
Reactive Attachment Disorder:

Internalizing disorder with
depressive symptoms and
withdrawn behavior

Disinhibited Social Engagement:

Externalizing behavior marked by
disinhibition
Posttraumatic Stress Disorder (PTSD)

❖ Criterion A (stressor): more explicit about the traumatic
event (i.e., directly, witnessed, indirectly)
❖ Eliminated Criterion A2 (subjective reaction)
❖ 3 symptom clusters (DSM-IV): now 4 (re-experiencing,
avoidance, arousal, persistent negative alterations of
mood and cognition)
❖ Lowered thresholds for children and adolescents
❖ Separate criteria for children 6 years of age or younger
PTSD: Criteria
❖ Exposure to actual or threatened death, serious injury, or sexual violence
❖ Presence of one or more intrusion sxs (e.g., distressing memories or dreams,
flashbacks, marked physiological reactions)
❖ Persistent avoidance of stimuli (e.g., avoidance of reminders of the trauma,
such as location, people, situations)
❖ Negative alterations in cognitions and mood (e.g., negative beliefs, distorted
beliefs, negative emotional states, diminished interests, detachment)
❖ Marked alterations in arousal and reactivity (e.g., irritable behavior, angry
outbursts, hypervigilance, exaggerated startle response, sleep disturbance)
❖ Duration: more than 1 month
PTSD: Associated Features

❖ Loss of language in young children may occur
❖ Auditory pseudo-hallucinations may occur (hearing one's
thoughts spoken in different voices)
❖ Difficulties in regulating emotions or maintaining stable
interpersonal relationships
❖ Highest rates (U.S.): survivors of rape, military combat and
captivity, ethnically or politically motivated internment and
genocide
❖ Onset: usually begins w/in first 3 months after trauma
PTSD: Prognostic Factors

❖ Pretraumatic: childhood emotional problems and prior
mental disorders; lower SES, lower education; exposure
to prior trauma; lower intelligence; family h/o
psychiatric illness; female gender and younger age
❖ Peritraumatic: severity of trauma, personal injury,
interpersonal violence, dissociation during the trauma
❖ Posttraumatic: negative appraisal, inappropriate coping
strategies, quality of social support, subsequent adverse
life events, trauma-related loss
PTSD: Treatment
Barcelona 2004
❖ cognitive-behavioral:
exposure, cognitive
restructuring, anxiety
management
❖ medication: SSRIs
What are the differences among

PTSD, Acute Stress Disorder, and
Adjustment Disorder?
PTSD & Acute Stress: more than 1

month vs. 1 month or less

Acute Stress & Adjustment:

Trauma vs. stressor
PTSD: ICD-10
❖ DSM-5 more consistent with ICD-10
❖ ICD-10 PTSD: response to a stressful event or situation
(either short- or long-lasting) of an exceptionally
threatening or catastrophic nature, which is likely to
cause pervasive distress in almost anyone (e.g., natural
or man-made disaster, combat, serious accident,
witnessing the violent death of others, or being a victim
of torture, terrorism, rape, or other crime)
❖ Note the more global definition of ICD-10
Review Questions
Review
❖ Three weeks ago R.J. was involved in a serious car accident in which his
best friend is killed. He subsequently exhibits emotional detachment,
derealization, amnesia, and nightmares about the accident. He avoids
the intersection where the accident occurred and has been having
trouble concentrating and sleeping and is uncharacteristically irritable.
Based on these symptoms, the best diagnosis is which of the following?
❖ A. Acute Stress Disorder
❖ B. PTSD
❖ C. Adjustment Disorder
❖ D. Brief Psychotic Disorder
Review
❖ In PTSD negative appraisals, inappropriate coping
strategies, and development of acute stress disorder are
types of temperament that may affect prognosis and
course of the illness. These are which types of factors:
❖ A. pretraumatic factors
❖ B. peritraumatic factors
❖ C. posttraumatic factors
Review
❖ Carlos is 6 months old. He actively interacts with almost any adult
he encounters, including total strangers. He does not seem to
check back with his Mama and Papa after being away from them,
even for an extended period of time. He seems to go off with
unfamiliar adults with minimal or no hesitation. Carlos might fit
criteria for which of the following:
❖ A. Reactive Attachment Disorder
❖ B. Disinhibited Social Engagement Disorder
❖ C. Selective Mutism
❖ D. None of the above
Tokyo 2005
DSM-5 (page 329)
Feeding & Eating What? Why? How?
Disorders
Feeding & Eating Disorders
❖ Pica & Rumination Disorder

❖ Avoidant/Restrictive Food Intake Disorder
❖ Anorexia Nervosa
❖ Bulimia Nervosa
❖ Binge Eating Disorder
Feeding & Eating Disorders
❖ Feeding & Eating Disorders of Infancy or Early

Childhood
❖ Pica & Rumination Disorder: criteria revised to allow
diagnosis for individuals of all ages
❖ Avoidant/Restrictive Food Intake Disorder: expanded
to capture a wide range of clinical presentations
What is the difference between pica

and rumination?
Pica: persistent eating of

nonnutritive, nonfood substances

Rumination: repeated
regurgitation of food, which may be
re-chewed, re-swallowed, or spit
out
What is a key distinction between

Avoidant/Restrictive Food Intake
Disorder and Anorexia Nervosa,
though both can lead to significant
weight loss?
Avoidant/Restrictive: e.g., lack of

interest in food because of its
texture

Anorexia: fear of gaining weight or

becoming fat
Anorexia Nervosa
❖ Amenorrhea: requirement is
eliminated
❖ "Significantly low weight":
additional clarification and
guidance are provided
❖ Criterion B ("overtly
expressed fear of weight
gain"): addition of "persistent
behavior that interferes with
Los Angeles 2007
weight gain"
Anorexia: Criteria
❖ Restriction of energy intake relative to requirements, leading to a
significantly low body weight in the context of age, sex, developmental
trajectory, and physical health.
❖ Intense fear of gaining weight or of becoming fat, or persistent
behavior that interferes with weight gain, even though at a significantly
low weight.
❖ Disturbance in the way in which one's body weight or shape is
experienced, undue influence of body weight or shape on self-
evaluation, or persistent lack of recognition of the seriousness of the
current low body weight
❖ Severity: measured on body mass index (BMI)
Anorexia: Associated Features

❖ Significant and potentially life-threatening medical conditions:
damage to major organ systems, amenorrhea, vital sign
abnormalities, bone density loss
❖ Depressed mood, social withdrawal, irritability, insomnia, and
diminished interest in sex
❖ Obsessive-compulsive features are common (e.g., preoccupied
with thoughts of food)
❖ Other concerns: eating in public, feelings of ineffectiveness,
strong desire to control, inflexible thinking, limited social
spontaneity, overly restrained emotional expression
Anorexia: Associated Features (Cont'd)
❖ Onset: during adolescence or young adulthood (rarely

before puberty and rarely after 40), typically associated
with stressful life event
❖ More common among females than males
(approximately 10:1)
Anorexia: Etiology & Treatment

Etiology Treatment

- temperamental: anxiety disorders or - first line of tx: weight gain in order
obsessional traits in childhood to avoid or reduce medical
- environmental: cultures and settings complications (which may require
in which thinness is valued hospitalization)
- genetic: first-degree biological - cognitive therapy: correct cognitive
relatives with the disorder; abnormal errors and erroneous beliefs about
serotonin levels weight and food
- research in U.S.: (a) more common in - family therapy: reduce high levels of
middle or upper class families expressed emotion (negative and
(despite an outward appearance of critical attitudes and comments)
adjustment and stability), (b) families
who are competitive and overly
concerned with approval and success
Bulimia Nervosa & Binge Eating Disorder
Binge Eating Disorder

Bulimia Nervosa ❖ Appendix B (DSM-IV):

now in the main body
❖ Frequency of binge eating
of the text
and inappropriate

compensatory behavior, 2x ❖ Frequency: now 1x
week for 3 months (DSM-IV):
week for 3 months
now 1x week for 3 months
(similar to Bulumia
Nervosa)
Review Questions
Review
❖ The first line of treatment for individuals with

Anorexia Nervosa is:
❖ A. individual therapy
❖ B. family therapy
❖ C. weight gain
❖ D. hospitalization
Review
❖ True or False. In the DSM-5, Pica and Rumination

Disorder exclusively occur only among children.
Review
❖ In both Binge Eating Disorder and Bulimia Nervosa,
symptoms must persist in which of the following
ways in order to meet criteria:
❖ A. approximately 1x/week for 3 months
❖ B. approximately 2x/week for 3 months
❖ C. approximately 1x/week for 4 months
❖ D. approximately 2x/week for 4 months
Review
❖ True or False. Individuals with Anorexia Nervosa

might engage in binge eating or purging behavior.
Review
❖ Which of the following is least likely to elevate

suicide risk?
❖ A. PTSD
❖ B. Anorexia Nervosa
❖ C. Bulimia
❖ D. Binge-Eating Disorder
Honolulu 2009
DSM-5 (page 481)
Substance-Related & What? Why? How?
Addictive Disorders
Note on Terminology: Substance Use
❖ Intoxication
❖ Withdrawal
What is intoxication?
Intoxication:

Development of a reversible
substance-specific syndrome due to
the recent ingestion of a substance.
Symptoms vary by substance.
What is withdrawal?
Withdrawal:

Development of a substance-specific
problematic behavioral change, with
physiological and cognitive
concomitants, that is due to the
cessation of, or reduction in, heavy and
prolonged substance use. Symptoms
vary by substance.
Substance-Related & Addictive Disorders
❖ Gambling Disorder (new)

❖ Criteria and Terminology
Gambling Disorder
Mexico City 2011
❖ New disorder
❖ Why: (a) to reflect increasing
evidence that the disorder
activates brain reward system
similar to substance use and (b)
to show that gambling
resembles substance use
disorders (to some extent)
Substance-Related & Addictive Disorders
❖ Substance abuse + substance dependence = substance

use disorder (i.e., no separate diagnoses)
❖ Substance-related legal problems: deleted, all other
criteria similar to DSM-IV
❖ New criterion: craving or strong desire or urge to use a
substance
❖ Threshold, 1 or more for abuse and 3 or more for
dependence (DSM-IV): now 2 or more
Substance Use Disorder: Criteria

large amounts needed activities given up

desire to cut down use when hazardous

time spent in pursuit use despite physical problem
exacerbation
craving
tolerance
failure of roles
withdrawal
use despite interpersonal issues
Substance Use Disorder: ICD-10
❖ There are many many substance use diagnoses in the

ICD-10
❖ For example: In the DSM-5, there are 10 distinct
diagnoses related to the use of cannabis (marijuana). In
the ICD-10, there are over 40!
❖ ICD-10 retains the distinction between abuse and
dependence
Gambling Disorder: Criteria

❖ Persistent and recurrent problematic gambling behavior leading to
clinically significant impairment or distress in a 12-month period
❖ Needs to gamble with increasing amounts of money in order to
achieve the desired excitement
❖ Is restless or irritable when attempting to cut down or stop gambling
❖ Has made repeated unsuccessful efforts to control, cut back, or stop
gambling
❖ Is often preoccupied with gambling
❖ Often gambles when feeling distressed
See DSM-5 (page 585) for additional symptoms.
Gambling Disorder: Associated Features

❖ Distortions in thinking (e.g., denial, superstitions, a sense of power
and control over the outcome of chance events, overconfidence)
❖ Money is both the cause and solution of their problems
❖ Impulsive, competitive, energetic, restless, and easily bored; overly
concerned with the approval of others and may be generous to the
point of extravagance when winning
❖ Depressed, lonely; may gamble when feeling helpless, guilty, or
depressed
❖ Suicide risk: up to 50% have suicidal ideation, about 17% attempt
suicide
Gambling Disorder: Etiology & Treatment

Etiology Treatment

- temperamental: early gambling in - individual and/or group treatment:
childhood or early adolescence; (Gambler's Anonymous,
associated with antisocial personality Motivational Interviewing)
disorder, depressive and bipolar
disorders, and other substance use
disorders (especially alcohol)

- genetic: family h/o gambling;
moderate to severe alcohol use
among first-degree relatives
ICD-10
❖ Pathological gambling (as well as fire-setting and

stealing) is located with the Disorders of Adult
Personality and Behavior
❖ Pathological gambling (F63) is considered a Habit and
Impulse Disorder in ICD-10
Paris 2012
DSM-5 (page 591)
Neurocognitive What? Why? How?
Disorders
Neurocognitive Disorder (NCD)
❖ Delirium
❖ Dementia
❖ Major and Mild Neurocognitive Disorder
❖ Etiological Subtypes
Neurocognitive Disorder (NCD)
❖ Delirium and amnesic disorders: now under NCD

❖ Major and mild NCDs: (a) separate diagnostic criteria
and (b) followed by etiological subtypes (e.g., due to
Alzheimer's, due to Parkinson's, due to traumatic brain
injury)
❖ Delirium: criteria updated and clarified to reflect
current evidence
What is delirium?
Delirium
❖ A disturbance in attention (i.e., reduced ability to direct, focus, sustain,
and shift attention) and awareness (reduced orientation to the
environment)
❖ Disturbance develops over a short period of time (usually hours to a
few days), represents a change from baseline attention and awareness,
and tends to fluctuate in severity during the course of a day
❖ Additional disturbance in cognition (e.g., memory deficit,
disorientation, language, visuospatial ability, or perception)
❖ Direct physiological consequence of another medication condition,
substance intoxication or withdrawal, or exposure to a toxin, or is due
to multiple etiologies
What is dementia?
Dementia
❖ A disturbance characterized by multiple cognitive deficits
that include (a) some degree of memory impairment and (b)
aphasia, apraxia, agnosia, and/or impaired executive
functioning
❖ Memory impairment include both anterograde and
retrograde amnesia
❖ Deficits are progressive and irreversible
❖ Course and prognosis depend on the etiology (e.g., alcohol,
head trauma, HIV) and availability of effective treatment
Note on Terminology: Dementia
❖ aphasia
❖ apraxia
❖ agnosia
❖ anterograde amnesia
❖ retrograde amnesia
What is aphasia?
Aphasia
❖ deterioration in language functioning

❖ difficulty naming people and objects
❖ difficulty understanding written and spoken language
What is apraxia?
Apraxia
❖ difficulty executing motor actions (e.g., not able to

dress, eat, cook or perform familiar activities)
Agnosia
❖ inability to recognize and identify familiar objects and

people
What is anterograde amnesia?

What is retrograde amnesia?
Anterograde & Retrograde Amnesia

❖ anterograde amnesia: difficulty acquiring new information
❖ retrograde amnesia: inability to recall previously learned
material

NOW
RETROGRADE ANTEROGRADE
(PRESENT TIME)

Major Neurocognitive Disorder

❖ Evidence of significant cognitive decline from a previous
level of performance in one or more cognitive domains
(complex attention, executive function, learning and
memory, language, perceptual-motor, or social cognition)
❖ Disturbance interfere with everyday independence
❖ Specify whether due to:
❖ Alzheimer's disease, Lewy body disease, Vascular
disease, Traumatic brain injury, HIV infection, etc.
Mild Neurocognitive Disorder

❖ Evidence of modest cognitive decline from a previous
level of performance in one or more cognitive domains
(complex attention, executive function, learning and
memory, language, perceptual motor, or social cognition)
❖ Deficits do not interfere with capacity for independence
❖ Specify whether due to:
❖ Alzheimer's disease, Lewy body disease, Vascular
disease, Traumatic brain injury, HIV infection, etc.
How do we distinguish between

major and mild?

Table 1 (page 593) Neurocognitive

domains
Review Questions
Review
❖ Lionel is a 52-year-old man who recently had a motorbike accident.
He was not wearing a helmet and loss consciousness for a few
days. Though he is expected to make significant recovery, he has
found it increasingly difficult to put his clothes on, cook for
himself, or do other basic activities familiar to him. Lionel is
likely experiencing which of the following:
❖ A. aphasia
❖ B. anterograde amnesia
❖ C. apraxia
❖ D. retrograde amnesia
Review
❖ Lourdes is a 71-year-old woman with dementia. Given her family
history, it is likely a neurocognitive disorder of the Alzheimer's
type. When she holds a pencil in her hand, she struggles to
identify it. She finds it difficult to understand her family when
they speak to her, although her hearing is perfectly healthy.
Lourdes is likely experiencing which of the following:
❖ A. aphasia
❖ B. apraxia
❖ C. agnosia
❖ D. retrograde amnesia
Review
❖ True or False. In Neurocognitive Disorder of the

Alzheimer's type, the progressive decline in cognitive
functioning typically begins with retrograde amnesia
(i.e., the inability to recall previously learned
material).
Review
❖ True or False. Alzheimer's is more common in males

than in females.
Alubihod 2013
DSM-5 (Page 645)
Personality What? Why? How?
Disorders
Key: In DSM-5 the criteria for

personality disorders have not
changed from those in DSM-IV.
What is a personality disorder?

A personality disorder is an
enduring pattern of inner experience
and behavior that deviates markedly
from the expectations of the
individual's culture, is pervasive and
inflexible, has an onset in
adolescence or early adulthood, is
stable over time, and leads to distress
or impairment.
What are the 3 DSM-IV personality

disorder clusters?
(A)
ODD-ECCENTRIC:
Paranoid
Personality (B)
Schizoid Disorder DRAMATIC-
EMOTIONAL
Schizotypal Clusters Antisocial
Borderline
Histrionic
(C) Narcissistic
ANXIOUS-FEARFUL
Avoidant
Dependent
Obessive-Compulsive
Personality Disorders: ICD-10
❖ Cluster A: Paranoid, Schizoid, Schizotypal (Schizotypal

Disorder is not with Personality Disorders but with
Schizophrenia)
❖ Cluster B: Dissocial (DSM-IV: Antisocial), Emotionally
Unstable (DSM-IV: Borderline), Histrionic, Other
❖ Cluster C: Anxious (DSM-IV: Avoidant), Dependent,
Anankastic (DSM-IV: Obsessive-Compulsive)
Cluster A
What is Paranoid Personality

Disorder?
Paranoid Personality Disorder:

A pervasive distrust and

suspiciousness of others such that
their motives are interpreted as
malevolent, beginning by early
adulthood and present in a variety of
contexts
What is Schizoid Personality

Disorder?
Schizoid Personality Disorder:

A pervasive detachment from social

relationships and a restricted
range of expression of emotions
in interpersonal settings, beginning
by early adulthood and present in a
variety of contexts
What is Schizotypal Personality

Disorder?
Schizotypal Personality Disorder:

A pervasive pattern of social and

interpersonal deficits marked by acute
discomfort with, and reduced capacity
for, close relationships as well as cognitive
or perceptual distortions and
eccentricities of behavior, beginning by
early adulthood and present in a variety of
contexts
Cluster B
What is Antisocial Personality

Disorder?
Antisocial Personality Disorder:

A pervasive pattern of disregard

for and violation of the rights of
others, occurring since age 15
years
What is Borderline Personality

Disorder?
Borderline Personality Disorder:

A pervasive pattern of instability of

interpersonal relationships, self-
image, and affects, and marked
impulsivity, beginning by early
adulthood and present in a variety
of contexts
What is Histrionic Personality

Disorder?
Histrionic Personality Disorder:

A pervasive pattern of excessive

emotionality and attention
seeking, beginning by early
adulthood and present in a variety
of contexts
What is Narcissistic Personality

Disorder?
Narcissistic Personality Disorder:

A pervasive pattern of grandiosity

(in fantasy or behavior), need for
admiration, and lack of empathy,
beginning by early adulthood and
present in a variety of contexts
Cluster C
What is Avoidant Personality

Disorder?
Avoidant Personality Disorder:

A pervasive pattern of social

inhibition, feelings of
inadequacy, and hypersensitivity
to negative evaluation, beginning
variety of contexts
What is Dependent Personality

Disorder?
Dependent Personality Disorder:

A pervasive and excessive need to

be taken care of that leads to
submissive and clinging behavior
and fears of separation, beginning
variety of contexts
What is Obsessive-Compulsive
Personality Disorder?
Obsessive-Compulsive Personality
Disorder:

A pervasive pattern of preoccupation

with orderliness, perfectionism, and
mental and interpersonal control, at
the expense of flexibility, openness, and
efficiency, beginning by early adulthood
and present in a variety of contexts
...and now, let's get back to the

game.
Ultimatum Game
❖ Two people: one giver, one recipient

❖ The giver has $100 and must offer some or all of that
money to the recipient
❖ The recipient can accept or reject the money
❖ If s/he accepts the money, the other partner gets the
remainder; if rejects, no one gets the money
Who accepted the offer?

Who rejected the offer?
Why does this matter?

The Game by Joseph Henrich
❖ North Americans (e.g., Americans, Canadians) usually

offer a 50-50 split when they are the giver (Participant
1)
❖ When they are the receiver (Participant 2), they are
more likely to show an eagerness to punish their
partner for uneven splits at their own expense.
This suggests that Americans (and

probably many Westerners) show
the tendency to be equitable with
strangers, but that they punish
those they perceive as not equitable
or fair, even at their own expense.
❖ Henrich repeated this study with indigenous people in

South America (the Machiguenga).
❖ The offer from Participant 1 was more likely to be low.
❖ However, Participant 2 rarely refused even the lowest
possible amount.
"It just seemed ridiculous to the

Machiguenga that you would
reject an offer of free money. [...]
They just didn't understand why
anyone would sacrifice money to
punish someone who had the good
luck of getting to play the other
role in the game." - J. Henrich

❖ The study was repeated with 14 other small-scale societies,
from Tanzania to Indonesia.
❖ In no society (of the 14) did he find people who were purely
selfish - that is, who always offered the lowest amount and who
never refused a split.
❖ The average offer varied: e.g., In societies where gift-giving is
heavily used to curry favor or gain allegiance, the giver
(Participant 1) would often make overly generous offers in
excess of 60%, AND the receiver (Participant 2) would often
reject them. Something never observed among Americans!
New York 2011
Mental Illness is WEIRD
Cultural What? Why? How?
Considerations
In the U.S. it is common for

students in psychology courses
(e.g., Introduction to Psychology) to
participate in research studies
within their universities in order to
receive credit for the course.
Mental Illness is WEIRD
Source: The weirdest people in the world, Joseph Henrich

Psychology Research: Fact Sheet

❖ 68%: study participants/subjects from the U.S.
(between 2003-2007).
❖ 96%: participants from Western industrialized
countries (i.e., North America, Europe, Australia, and
Israel).
❖ 73%: first authors of research papers at American
universities.
❖ 99%: first authors of research papers at universities in
Western countries.
...so what?
Is it not possible that

American academics and
universities are particularly
productive in the area of
psychology/behavioral
science research?
Ninety-six (96%) of study

participants in psychology/
behavioral science research come
from countries with only 12% of
the world's population.
...67% of American study

participants and 80% of participants
from other countries are college
students in psychology courses.
Psychology/behavioral science
research does not reflect the
full breadth of human diversity.
Instead, we apply our
concepts/expectations of
normative human behavior
(e.g., mental illness) based on a
narrow population.
...based on WEIRD people.

WESTERN
EDUCATED
INDUSTRIALIZED
RICH
DEMOCRATIC
...people
San Francisco 2008
DSM-5 (page 749)
Cultural What? Why? How?
Formulation
Cultural Formulation: Then & Now

DSM-IV-TR DSM-5

- Provided a framework (Outline for - Expands an updated version of the
Cultural Formulation) for assessing Outline
information about cultural features of
an individuals' mental health - Utilizes an assessment: Cultural
problem and how it relates to a social Formulation Interview (CFI)
and cultural context and history
Outline for Cultural Formulation: DSM-5
❖ Cultural identity of the individual

❖ Cultural conceptualizations of distress
❖ Psychosocial stressors and cultural features of
vulnerability and resilience
❖ Cultural features of the relationship between the
individual and the clinician
❖ Overall cultural assessment
Note on Terminology: Cultural Formulation
❖ Culture
❖ Race
❖ Ethnicity
What is culture?
Culture:

Systems of knowledge, concepts, rules,

and practices that are learned and
transmitted across generations. Culture
includes language, religion and
spirituality, family structures, life-cycle
stages, ceremonial rituals, and customs, as
well as moral and legal system.
What is race?
Race:

A culturally constructed category of

identity that divides humanity into
groups based on a variety of
superficial physical traits
attributed to some hypothetical
intrinsic, biological characteristics.
What is ethnicity?
Ethnicity:

A culturally constructed group identity

used to define peoples and communities.
It may be rooted in a common history,
geography, language, religion, or other
shared characteristics of a group, which
distinguish that group from others.
Ethnicity may be self-assigned or
attributed by outsides.
Key: Culture, race, and ethnicity are related to

economic inequities, racism, and
discrimination that result in health disparities.

Cultural, ethnic, and racial identities can be

sources of strength and group support that
enhance resilience, but they may also lead to
psychological, interpersonal, and
intergenerational conflict or difficulties in
adaptation that require diagnostic assessment.
Cultural Formulation Interview (CFI): DSM-5
Why is it helpful?
❖ Difficulty in diagnostic assessment owing to significant differences in
the cultural, religious, or socioeconomic backgrounds of clinician and
the individual
❖ Uncertainty about the fit between culturally distinctive symptoms and
diagnostic criteria
❖ Difficulty in judging illness severity or impairment
❖ Disagreement between the individual and clinician on the course of
care
❖ Limited engagement in and adherence to treatment by the individual
Cultural Formulation Interview (CFI): DSM-5
Four domains of assessment:

❖ Cultural Definition of the Problem (questions 1-3): e.g., How would you
describe your problem?
❖ Cultural Perceptions of Cause, Context, and Support (questions 4-10): e.g.,
What do others in your family, your friends, or others in your community
think is causing the problem?
❖ Cultural Factors Affecting Self-Coping and Past Help Seeking (questions
11-13): e.g., Sometimes people have various ways of dealing with problems
like yours. What have you done on your own to cope with your problem?
❖ Cultural Factors Affecting Current Help Seeking (questions 14-16): e.g., What
kinds of help do you think would be most useful to you at this time?
Questions & Discussion

Sources
❖ American Psychiatric Association. (2013). Diagnostic and Statistical Manual of
Mental Disorders (5th Ed.).
❖ American Psychiatric Association. (2013). Highlights of Changes from
DSM-IV-TR to DSM-5.
❖ American Psychiatric Association. (2013). Understanding ICD-10-CM and
DSM-5: A quick guide for psychiatrists and other mental health clinicians.
❖ Roberts, J.M. (2014). More than just words and numbers: The top 15
fundamental changes to the DSM-5 and the transition to ICD-10.
❖ World Health Organization, Division of Mental Health. (1992). The ICD-19
classification of mental and behavioral disorders: Clinical descriptions and
diagnostic guidelines.
Ronald Del Castillo, PsyD, MPH(c)

(323) 539-7805 (US)
+63 93 6967-4718 (Philippines)
rdelcastillo@g.ucla.edu
***Email is best***
Thank you.

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COPYRIGHT DR.

RONALD DEL CASTILLO

University of the Philippines, Diliman, September 12, 2014

DSM-5 & ICD-10:

Key (Broad) Distinctions

Source: American Psychological Association

Who writes it?

American Psychiatric World Health Organization

Who approves it?

assembly of the American health ministers of all 194

What is the cost?

Who is the audience?

Where is the data from?

Field field trials in Field trials in 110

*ICD-10: The Philippines was not

ICD-10: A Closer Look

Who uses the ICD?

In your day-to-day clinical work, which classification system for

What are the implications?

Changes from DSM-IV-TR to DSM 5

DSM 5: Highlights What? Why? How?

*NOT an exhaustive list

More dimensionality with the use of - recognition that categorical ratings

Multiaxial System: Then & Now

More emphasis on comorbidity (e.g.,

- increasing evidence that obsessions,

New category: Trauma and Stressor- - stress-related disorders are grouped

Transformed: Neurodevelopmental - more emphasis on neurobiological

- limited evidence to show distinction

Transformed: (1) Depressive Disorders

- recognition that depressive episode

What we WILL cover What we WILL NOT cover

Neurodevelopmental Disorders Dissociative Disorders

DSM-5 & ICD-10: Diagnostic Codes

DSM-5 & ICD-10: Diagnostic Codes

If more than one code can be assigned

DSM-5 & ICD-10: Diagnostic Codes

Note on Terminology: Seminar-Workshop

What is Marisol experiencing?

"The symptoms cause clinically

DSM-5 (page 31)

Neurodevelopmental What? Why? How?

Intellectual Disability: Criteria

Intellectual Disability: Associated Features

Intellectual Disability: Etiology*

Intellectual Disability: Treatment

❖ PKU: may be prevented by diet

Intellectual Disability: ICD-10

Autism Spectrum Disorders

Autism Spectrum Disorders

Disorder + Childhood communication and social

Disorder NOS = Autism behaviors, interests, and

Autism Spectrum Disorders: Criteria

Autism Spectrum Disorders: Associated Features and Etiology

Associated Features Etiology

Asperger's & Autism: ICD-10

Attention-Deficit/Hyperactivity Disorder (ADHD)

IV (DSM-IV: prior to age 7)

facilitate application across autism spectrum disorder

neurodevelopmental symptoms, not 6 (as

ADHD: Associated Features & Etiology

❖ psychopharm: Ritalin and other CNS stimulants (both

Specific Learning Disorder